This form should be taken by the injured worker when he or she visits the doctor. The worker needs to fill out and sign the first part so that the doctor knows he or she has the worker’s permission to release important medical information to you. The doctor should fill out the rest of the form and sign it.
I hereby authorize the release to my employer of all medical information relating to the restrictions that affect my ability to fulfill my regular job duties.
Date
Fitness Assessment Results
Can this employee return to their full duties?
Days/week
Hours/day
Starting Date
Can this employee return to work if identified limitations are accommodated?
Days/week
Hours/day
Starting date
End date
Please indicate which activities he/she will not be able to perform or has limitations.
Bending
Twisting
Squatting/Kneeling
Vision
Hearing
Climbing
Reaching
Lifting/Carrying
Driving
Other (please explain)
In an 8 hour day, the employee may:
Stand (hours):
Walk (hours):
Sit (hours):
Drive (hours):
The employee is capable of:
Sedentary Physical Activities: Lifting less than 5kg mainly seated but occasionally standing or walking about.
Light Physical Activities: Lifting 5-10kg maximum and occasionally lifting and/or carrying such articles as dockets, ledgers, and small tools up to 5kg.
Medium Physical Activities: Lifting 15-25kg maximum with frequent lifting and carrying of objects weighing up to 12kg.
Heavy Physical Activities: Lifting 44kg maximum with frequent lifting and/or carrying of objects weighing up to 22kg.
The employee may use hand(s) for repetitive:
Single Grasping
Pushing and Pulling
Keyboarding
Writing
What type of worksite modification might help in expediting his/her return?
Temporarily________________________ for how long?
Permanently
In cases of stress, please outline in detail the work site stressors and suggested modifications required. Include any environmental or irritant conditions that may need to be addressed. (Please use a separate sheet if additional space is required.)
Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
Please, finish the registration to access the content of the checklist.
